An 89-year-old man died after falling on concrete and banging his head at his retirement home in Devon, an inquest has heard.

William Caldwell died on August 6 at Derriford Hospital, after the unwitnessed fall in the garden at Warwick Park Care Home in Plymouth on July 30.

In December last year the care home was rated inadequate and placed into special measures.

An inquest in Torquay on Tuesday heard that the Dumbarton-born retired clerk, who was divorced, was smelling of alcohol at the time of the incident.

Joanne Clifford, manager of the retirement home in Butt Park Road, said in a statement that Mr Caldwell, who had been a resident since January 2016, had a chronic alcohol problem and would ‘take himself off to bed when he had too much’.

Warwick Park Care Home (Image: Google)

She said at around 7pm on July 30, he was alone on the patio, having spent the afternoon with other residents. He was heard to fall over by a care worker, who went out and found him on the floor. The care worker immediately called an ambulance which took him to hospital.

Dr Jane Stribley, a consultant at Derriford Hospital, described in a statement Mr Caldwell’s stay in the hospital and how his family agreed to move to a palliative approach.

Coroner Ian Arrow said: “On July 30, he fell and severely injured his brain. It resulted in immobility and his then contracting pneumonia.” He recorded an accidental death.

A report published by the health watchdog into Warwick Park at the end of 2016 highlighted several failures of care, including safeguarding issues, poor management and lack of training for staff giving medicines.

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Findings also include people’s mental capacity not always being assessed, a lack of care plans, and health needs not always being met.

The inspectors rated the care home, which looks after up to 50 older and younger adults, some with dementia or physical or sensory health needs, as ‘inadequate’ in four areas – and ‘requires improvement’ in a fifth.

Despite this, the report states many residents “were happy” and “felt cared for”. It says inspectors observed “kind interactions” between people and staff throughout the visit.

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It adds the management team has been “proactive” in making improvements and are “willing to learn from mistakes”.

The care home, on Butt Park Road, was first inspected on September 1, 2016. Subsequent visits were made on September 6 and 28, and the report was published two months later.

This followed two visits in December 2014 and March 2015 when the home was asked to “make improvements.”

It continues: “At the last inspection in March 2016 we found there were not always enough staff present to care for people safely, medicine management was not safe, and infection control practices were not robust.

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“We also found risk assessments were not always reflective of people’s identified needs, updated accurately and followed.

“We told the provider they had until the June 18, 2016, to put this right. At this inspection we found improvements had been made in relation to staffing and infection control practices however, further improvements relating to the management of medicines and risk assessment was required.

“Although the registered manager and staff were making changes to the way medicines were managed, at the time of inspection people’s medicines were not always managed safely.”

Although some improvements were made, the report says the home has room to improve, and must do so or risk closure. However it highlights many positives, including new care plans, staff going out of their way to buy specific products for patients’ needs and “homemade and nutritious” food being cooked daily.

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The report says: “The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

“The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.”